Identify.
Recognise the signals. Surface the risk.
Clinical harm is not always sudden or unforeseeable. Changes in patient condition, abnormal results, repeated concerns, delayed responses and inconsistencies in clinical records may provide early indications that something is wrong.
Yet these signals can be missed, considered in isolation, minimised or lost as patients move between clinicians, departments and care settings.
The Clinical Investigation Division uses structured analysis to identify potential adverse clinical events, emerging risks and recurring patterns of harm.
Our purpose is to make the signals visible — and determine what they mean.
The problem
The information may be there. The warning may not be recognised.
Clinical information is generated continuously, but it does not always translate into effective clinical action.
Observations, pathology, medication changes, clinical notes, patient concerns and escalation records may each reveal part of a developing problem.
Individually, these records can appear unremarkable. Examined together, and in chronological context, they may reveal a different picture.
We identify the patterns that isolated reviews may overlook.
Our analysis examines how signals emerge, accumulate, change and interact over time — including whether they were recognised, interpreted, communicated and acted upon.
How separate signals become a pattern
Illustrative example — not drawn from a real case.
- 1Heart rate begins trending upward, within normal limits.
- 2Inflammatory markers elevated; result not reviewed that shift.
- 3Nursing note records the patient as “not themselves”.
- 4Family raises a concern at the bedside.
- 5Respiratory rate rises; early warning score stays below threshold.
- 6Medical review requested; response delayed.
- 7Analgesia increased; underlying cause not reassessed.
- 8Patient discharged; re-presents to the emergency department 48 hours later.
No single entry crossed a threshold. Read together, in sequence, the pattern was visible from day 2.
Our capabilities
Methods for making signals visible.
FIRST-PASS
Preliminary Clinical Safety Review
An early assessment of whether the evidence warrants further investigation.
FIRST-PASS provides a structured initial review of clinical records, events and concerns to identify potential adverse outcomes, inconsistencies, unexplained clinical developments and indicators of preventable harm.
FIRST-PASS is based on an internationally recognised adverse event trigger tool, expanded and enhanced through cluster analysis, clinical signal trajectory, response latency, consent, disclosure and preliminary record analysis.
The assessment establishes what is known, what remains uncertain and which issues require closer examination.
Typical outputs
- Preliminary chronology of relevant clinical events
- Identification of potential adverse events and clinical warning signals
- Evidence gaps, inconsistencies and unresolved questions
- Preliminary assessment of the need for further investigation
- Recommended next steps
FIRST-PASS is an initial evidence assessment, used to identify potential harm events.
PASS+
Patient Adaptive Safety Surveillance
Patient-specific surveillance of emerging clinical risk.
PASS+ is our patient-adaptive safety surveillance tool.
Rather than relying solely on generic thresholds, the model considers changes in the context of the individual patient's condition, clinical history, treatment and evolving observations.
It is designed to support recognition of emerging deterioration and combinations of signals that conventional monitoring may not adequately identify.
A core component of PASS+
Signals Trajectory
Following the development of risk — understanding how clinical warning signals develop over time.
A fundamental aspect of PASS+ is Signals Trajectory, which reconstructs the progression of clinical indicators across a patient's entire episode of care (including what happens after hospital discharge).
It examines the relationship between emerging clinical evidence, interpretation, communication, decision-making and response.
Particular attention is given to changes in patient condition, repeated warning signs, clinical deterioration and transitions between care settings.
The analysis helps establish when risk became apparent, how it developed and where opportunities for recognition or intervention may have occurred.
CORA
Clinical Observation & Risk Analyser
Bringing clinical records and risk signals into a connected analytical picture.
CORA is our clinical information analysis capability, designed to support structured interrogation of clinical records, observations, decisions and patterns of risk.
It brings together information that may otherwise remain fragmented across clinical documentation.
CORA supports the identification of candidate signals and relationships for further assessment. Its outputs require appropriate clinical and investigative verification.
The platform is being constantly improved and enhanced, with capabilities being progressively added and tested as new cases, data, and capabilities emerge.
From signals to understanding
Identification is the beginning, not the conclusion.
A detected signal is not, by itself, proof of clinical error, negligence or preventable harm.
Its significance must be established through the evidence, the clinical circumstances and the decisions reasonably available at the time.
CID distinguishes between observed facts, analytical indicators, potential risks and established findings.
Observed facts
Analytical indicators
Potential risks
Established findings
Where further examination is warranted, clients may decide to progress to our CASE investigation process, which provides a structured means of determining what happened and why.
Begin with the evidence
Concerned about an adverse clinical event or unexplained outcome?
FIRST-PASS provides a defined starting point for understanding the available evidence and determining whether more detailed investigation is appropriate.